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PERMIT-T4E NAME/ADDRESS(Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES) <br /> Facility Name/Locationijdijjerent) DISCHARGE MONITORING REPORT IDMR) <br /> It <br /> 1-16 17-19 <br /> ADO Esf' <br /> PERMIT NUMBER DISCHARGE NUMBER <br /> ---- —`----- -------- MONITORING PERIOD <br /> t<Acl LITv <br /> ---------------- --- YEAR MO I DAY I YEAR MO DAY <br /> LOCATION FROM TO <br /> (zo-zt) (22-23) (24-25) (26-27) (28-29) (30-31) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-45) (46-53) (54-61) NO. FREQOUFENCY SAMPLE <br /> (31-37) EX ANALYSIS TYPE <br /> >< AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS 62-63) (64-68) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - :� '< "e, , -• ' <br /> FIEQUIREMEN'E' <br /> r SAMPLE <br /> MEASUREMENT <br /> t,. .ti I CtFtTf *cvft-14 4 1PI ft..a 3=gymIrs: +�asRr< <br /> • s <br /> - RE4tiiREAl15F4T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT PERMIT <br /> SAMPLE <br /> RttCyijFREMEFF'C, n r -�h y,� <br /> f ¢ <br /> SAMPLE <br /> 1 <br /> MEASUREMENT <br /> PERMIT <br /> REpE111�k�fiIEAFT <br /> SAMPLE <br /> MEASUREMENT <br /> P$kM 1T <br /> REQVEREtA#7V!' <br /> SAMPLE <br /> MEASUREMENT <br /> PERi4FtT ' <br /> IkE#?U I REM EN'1 <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT 1 HAVE PERSONALLY EXAMINED r TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN AND BASED <br /> l ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION I BELIEVE THE SUBMITTED INFORMATION <br /> / IS TRUE ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG j t,�,- k!•/yl- /.Ti - <br /> NIFICAN7 PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING •* y/ % f / <br /> THE POSSIBILITY OF FINE AND IMPRISONMENT SEE 18 USC S 7001 AND SIGNATURE OF PRINCIPAL EXECUTIVE '— :-• J� } :x.,!'"� r •-�{ <br /> 33 USC S 1319 lPenalt"., under thew t.tat- may mr/ode fa,- up lu SlatXXt <br /> TYPED OR PRINTED aiut or masm�umrmp--tmentu(hetuwen 6 month,and.ijean OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> L CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> EPA Form 3320-1 (Rev.9-88) Previous editions maybe Used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />